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PE.ITRUCTION SPECIFICAMI.in i <br />Sealing Material from 1 l'" ft tics to 0 I ft bgs Filler Material from tt bgs to Well casing to be EteristatEl by gm of the followina methods;. from ft bgs to ft bgs 0 Mille Knife Number of cuts every ft and/or <br />Explosives 0 Detonating cord 0 wIth prolectIles every n o without proiectile <br /> <br />0 Detonating cord and boosters 0 wtth projectiles every ft 0 without profectile Other <br />tt bgs <br />g Material r Neat Cement (94 lb brey5-6 gal water) Sand Cement <br />Bentonite (20% solids) LI Manufacturer Spec 'Y. solids_ % Name <br />P nt Method 1 Pumped 1 Free Fall) <br />Seal Completion I Complete with Mushroom Cap <br />- <br />sack mix/7 gal water ' Bentonite Pellets <br />Specs on File I Specs Submitted <br />Complete to Existing Surface Pad <br />7 Other <br />ti 90s <br />"mon. <br />WELL DESTRUCTION PERMIT <br />PUBLIC WATER SYSTEM 0 Yes 0 No <br />SAN JOAOUIN COUNTY EtNIRONMENTAL HEALTH DEPARTmENT <br />1868 East Hazelton Avenue - STOCKTON CA 95295 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />Joe ADDRESS '-_..ft i M II. Ai C riv OF M11•1 061 1?)/0 <br />CROSS STREET VOW 11-gA <br />APN KAMM. PARCEL S _g_LAND USE APPUCATION II <br />OWNER 11 WifilDAPP: PDDNE 7061' ?)go - 9g71) <br />OWNER ADDRESS 14* . gr i <br />y C-57 WELL DRILLING LICENSE NUMBER EXPIRATION DATE <br />PEREDRATIGH CONTRACTOR PHONE <br />PERFORATION CONTRACTOR ADDRESS Cm/STATE/ZIP <br />CommAcTort <br />CONTRACTOR ADDRESS <br /># , <br />110 ' I rc 11 <br />I It. I <br /> <br />CITY/STATE/ZIP <br />PHONE 2,0 <br /> <br />cinisTATEmp <br />'31 742,1 <br />C-57 Well Drilling <br />Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives <br />CHP Hazardous Material Transportation for Explosives <br />San Joaquin County Sheriff-Coroner Explosives Application and Permit <br />California Occupational Safety Health - Blaster <br />License Number Expiration Date <br />License Number Expiration Date <br />License Number Expiration Date <br />License Number Expiration Date <br />License Number Expiration Date <br />Iliameusailanutosai141, bl:fry 0 Replacement Well 10 Caved In 0 Pit Well <br />Detected/Suspected Well W ontamlnange) <br />0 InaCtive 0 Test Hole <br />Adjacent property with contarninetion (Address) <br />Known Soil/Water contaminants at adjacent properly <br />gIstsTeta WELL ConsTnucroff DEUX 0 Open Bottom Gravel Pacit Unposed 0 Other <br />Well Log copy attached 0 Yes No Grout Seal 0 No <br />$,.. <br />0 Yes It below ground unlace (bga) Hole Diameter <br />Weil Conductor Casing 0 Yes 0 No Depth of Corjr Casing 11 <br />Well Casing Diameter. <br />s Diameter of Conductor Casing <br />" inch" Total Depth li Depth to Water <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATTON AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CAUFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. <br />riches <br />Inches <br />ft Depth of Casing Ftbgs <br />CONTRACTORS StatuTuRE <br />I <br />6 <br />M ADVANCE NOTICE REQUIRED FOR INSP CTIONS <br />/b TritEprii0 ouxik DATE Oq 24-)4' YmeN , <br /> 28 2 <br /> kt'v Coutvt„ <br />cNr <br />DEPARTMENT USE ON <br />Application Accepted By Date (.7 <br />Destruction Inspection By '7Y/Chir..- S:374/ 2011 We <br />COMMENTS The In 1-i. ow. b c sh,j) j+ , bev y d r. <br />d • AO <br />CD` <br />Area CI iq <br />Employee ID4 <br />P 1/ Pvl LotiCin 1v,1 IntQf (v. /11 e( ( _Ste , 01_1 <br />_ „ . .... - '79 --` "" ' ' i r J L , , — L-, ) <br />PE <br />Codas <br />SC <br />Info <br />Received Medd/ Amount <br />Remttted Date Permit/ <br />Seeder! Rectop • Invoice I Well IDS <br />143 4 C060 .7?"-) ft_ / . f ,..,2 ..., / - ri.ls? r u \-3iAk,141-1.1-.-1-- <br />, A .1 i <br />WELL DESTRUCTION PERMIT